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Outline of Talk• Benefits of treatment and early treatment• Current linkage to care status in the US• NHAS goal for linkage to care• Cost-effectiveness analysis of achieving the NHAS goal• Threshold cost of linkage to care intervention to achieve NHAS goal – Intervention cost below which achieving the NHAS goal will be cost-effective 1

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Benefits of Treatment• Antiretroviral therapy (ART) has increased the life expectancy of HIV-infected persons (Antiretroviral Therapy Cohort Collaboration study, Lancet 2008) – Life expectancy in period1996-99 when ART was first implemented • 36 years for those on treatment at age 20 • 25 years for those on treatment at age 35 – Life expectancy in period 2003-05 • 49 years for those on treatment at age 20 • 37 years for those on treatment at age 35 – Approximately 13 year increase over this time period• Approximately 80% of persons on ART have an undetectable viral load (Gardner et. al., CID, 2011) – Reduces risk of heterosexual HIV transmission by 90% 2

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Benefits of Early Treatment• Successful viral load suppression is higher when treatment is started early in the disease stage – Persons delaying treatment until CD4 count of <200 cells/µL might not achieve a normal CD4 count even after a decade of effective treatment (Kelley et. al., CID, 2009)• Life expectancy is higher with early treatment (Antiretroviral Therapy Cohort Collaboration study, Lancet 2008) – chances of surviving to age 44 for those on treatment at age 20 was • 60% when treatment started at CD4 count of <100 cells/µL • 90% when treatment started at CD4 count of ≥200 cells/µL 3

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Current Statistics on HIV-infected Individuals Linked to Care in the U.S.• Although 80% of people living with HIV/AIDS are diagnosed (Gardner et. al., CID, 2011; Marks et. al. AIDS 2010) – only 65% of diagnosed persons enter initial care within 3 months of diagnosis – 50% of those diagnosed are not engaged in care, – those on treatment constitute only approximately 24% of people living with HIV/AIDS• Increasing early linkage to care is essential for HIV- infected individuals to fully benefit from early diagnosis and the availability of effective therapy 4

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National HIV/AIDS Strategy (NHAS)• The NHAS released in 2010 by the White House – developed to identify areas of change that will help reduce HIV incidence, increase access to care and optimize health outcomes of HIV-infected individuals, and reduce HIV-related health disparities• One of the goals of the NHAS is to • increase the proportion of newly diagnosed HIV-infected persons entering care within 3 months of diagnosis from 65% to 85% 5

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OBJECTIVE OF RESEARCH• Analyze cost-effectiveness of achieving NHAS goal for linkage to care – increase the proportion of newly diagnosed HIV-infected persons entering care within 3 months of diagnosis from 65% to 85%• Obtain threshold cost of linkage to care intervention – Cost below which an intervention would be cost-effective 6

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Methods• Cost-effectiveness measure – incremental cost-effectiveness ratio (ICER or the change in costs / change in the quality-adjusted life years (QALYs)) – Costs estimated from provider perspective• To estimate life-time treatment costs and QALYs for HIV-infected individuals we used the Progression and Transmission of HIV/AIDS (PATH) model – PATH is a simulation model that tracks HIV-infected index persons through disease phases from time of infection to death (Prabhu, et al., PLoS One 2011, 6(5))• PATH run under two linkage to care scenarios: current and the NHAS goal – Simulated 10,000 individuals and estimated the average life-time costs and QALYs per index person in each scenario to obtain the ICER of achieving the NHAS goal 7

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Linkage to Care Intervention Cost• Cost of intervention to achieve the NHAS goal was assumed as $600 per person diagnosed – Based on costs data from ARTAS (Antiretroviral Treatment Access Study, AIDS, 2005) – ARTAS was a case management trial conducted in health departments and CBOs in the U.S. in partnership with CDC• Due to limited data on intervention costs, we also estimated the threshold program cost under which the intervention would be cost-effective – i.e., program cost that would provide an ICER of < $100,000 per QALY gained 9

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Sensitivity Analysis: Retention and Re-entry to Care Retention in care Re-entry to care 100% of those linked wereBase case Not applicable retained in care Of those linked to care: Of those who dropped out of care: •26% were retained in care •27-60% re-entered care within 1Sensitivity •39% dropped out of care in to 2 years analysis 1.5 to 2 years (Gardner et. al., CID, 2011) case •And remaining 35% •The rest re-entered when their dropped out in 3 to 5 years CD4 count dropped to either 200 (Marks et. al., AIDS 2010) or 36 cells/µL 11

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Summary of Results• Achieving NHAS goal* generated the following average measures per HIV diagnosed index person – an ICER of $51,950 per QALY gained with ARTAS-type intervention – a delay of 3 years in the onset of AIDS – an increase in life expectancy of 1.16 years – prevention of 263 cases of life-time transmissions per 10,000 diagnosed persons*Increasing the proportion linked to care within 3 months of diagnosis to 85% from 65% 13

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Summary of Results (cont.)• Threshold average program cost below which an intervention is cost-effective (ICER of <100,000 per QALY gained) • $28,406 per diagnosed person when considering 100% retention • $23,205 to $28,059* per diagnosed person when retention was <100%* Range based on different proportions of retention and re-entry to care 14

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Limitations• Estimated only first-level transmissions, hence underestimating the number of transmissions averted• Limited data on efficacy and cost of intervention program to increase linkage to care 15

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Discussion and Conclusions• Benefits of early diagnosis and availability of effective treatment can be fully realized only when diagnosed individuals are linked to care to start timely treatment• Achieving the NHAS goal of increasing the proportion linked to care within 3 months of diagnosis from 65% to 85% was cost-effective – Achieving the NHAS goal increased average life-expectancy and delayed onset of AIDS or death – The above results held even when retention in care was less than 100%• An intervention program could cost up to approximately $28,400 per diagnosed person and still be cost-effective 16

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Thank you!For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: http://www.cdc.govThe findings and conclusions in this report are those of the authors and do not necessarily represent the official position ofthe Centers for Disease Control and Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention